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208 Cards in this Set

  • Front
  • Back

what is the most common of death in united states?

coronary artery disease
what are the risk factors for coronary artery disease?
1. diabetes
2. hypertension
3. tobacco use
4. hyperlipidemia
5. peripheral arterial disease
6. obesity
7. inactivity
8. family history
when is the family history significant for coronary artery disease?
1. female relative <65
2. male relatives < 55
is emotional stress risk factor for CAD?
1. no
2. hard to measure
what presentations on history and physical exam exclude coronary artery disease?
1. chest pain does not change with respiration or body positions

2. CAD is not associated with chest wall tenderness

3. if these are present, pt does not have cad
what are the causes of pleuritic pain?
1. PE
2. pneumonia
3. pleuritis
4. pericarditis
5. pneumothorax
what is the cause of chest pain that is positional?
pericarditis
what is the cause of chest pain that in tender to palpation?
costochondritis
a pt presents to ER with chest pain. the pain also occurs in the epigastric area and pt also has sore throat, bad metallic test in the mouth and a cough. what do you recommend?
give PPI
an alcoholic comes to the ER with chest pain. pt has nausea and vomiting and epigastric tenderness. what do you recommend?
check amylase and lipase
a pt comes to ED with chest pain. there is right upper quadrant tenderness and mild fever. what do you recommend?
order abdominal sonogram for gallstones
what are the other symptoms of ischemic heart disease?
1. dull pain
2. lasting 15-30mins
3. occuring on exertion
4. in a substernal location
5. radiating to the jaw or left arm
what does S3 heart sound on chest exam mean?
dilated left ventricle
what does S4 heart sound on chest exam mean?
left ventricular hypertrophy
rales on lung exam mean what?
congestive heart failure
what is the best initial test for chest pain that is not pleuritic, tender, or positional?
EKG
what is the most accurate diagnostic test for ischemic chest pain?
ck-mb or troponins
what is the main difference b/w ck-mb and troponins?
1. ck-mb only stays elevated 1-2 days and while troponins stay elevated 1-2 weeks.
what tests would you order if pt has reinfarction?
ck-mb
what cardiac marker rises first?
myoglobin
when do you order stress testing in CAD?
1. when the case in not acute presentation

2. initial ekg and enzymes test do not establish the diagnosis
pt comes to ED with chest pain, this was his first episode and he has no risk factors. in the ED he had normal ekg and normal ck-mb/troponins and release next day. what is the most appropriate in his further management?
1.stress testing

2. do this when the case is equivocal or uncertain for presence of CAD
what is positive stress test?
st depression during the test
when do i do dipyridamole or adenosine thallium stress test or dobutamine echo?
1. pt who cannot exercise to a target heart rate of >85%

2. copd pts
3. amputations
4. deconditioning
5. weakness/previous stroke
6.lower extremity ulcer
7. dementia
8. obesity
when do i do exercise thallium testing or stress echocardiography?
1. ekg is unreadable for ischemia
2. LBBB
3. digoxin use
4. pacemaker in place
5. left ventricular hypertrophy
6. any baseline abormality of st segment of the ekg
when do we do sestamibi nuclear stree test?
use in obese pts and those with larger breasts
if pt has abnormal stress test , what is the next step in managment?
angiography for ptca or cabg
what is the definition of acute coronary syndrome?
1. cause acute chest pain
2. can be with exercise or with rest
3. can have st segment elevation, depression or normal ekg
4. is not bases on enzyme levels, angiography or stress test results
what is the best initial therapy for all cases of ACS?
aspirin
what is the effect of aspirin?
it has instant effect on inhibiting platelets
what other therapies need to be instituted in ACS but they dont lower mortality?
oxygen, nitrates, and morphine
what other therapies lower mortality in STEMI?
thrombolytics and primary angioplasty lower mortality but they are time dependent
what is the time limit for performing angioplasty in ACS?
the must be performed with in 90mins of arrival at the ED of a pt with STEMI
If angioplasty cannot be performed within 90 mins, then what we do?
then pt should recieve thrombolytics
what are the indications for thrombolytics?
1. if you can't do angioplasty

2. when the pt has chest pain for <12hrs and

3. ST segment elevation in 2 or more leads

3. new LBBB
when shoud thrombolytics be give in STEMI?
within 30 mins of pts arrival to ED
what has the greatest efficacy in lowering mortality in STEMI?
urgent angioplasty or pcs
what other therapies need to instituted in ACS that lower mortality?
1. beta blocker - lower morality but they are not time dependent

2. ACEI or ARBs - give to all pts with acs but they only lower mortality if there is left ventricular dysfunction or systolic dysfunction

3. statins - if LDL is not at the goal
what are the indication for statin therapy in acs?
1. these meds are give to all pts with acs regardless of what ekg shows or troponins or ck-mb levels
list therapies that always lower mortality in acs?
1. asa
2. thrombolytics
3. primary angioplasty
4. metoprolol
5. statins
6.clopidogrel
list therapies that lower mortality in certain conditions in acs?
1. ace inhibitors if ejection fraction is low

2. ARBs if ejection fraction is low
what therapies dont lower mortality in acs?
1. oxygen
2. morphine
3. nitrates
4. calcium channel blockers
5. lidocaine
6. amiodarone
when is clopidogrel used ?
1. when has pt acs and is allergic to aspirin or pt is to undergo angioplasty
how does clopidogrel wor|k?
platelet angtagonist
when are the calcium channel blockers ( verapamil, diltiazem) used in acs?
1. the pt is intolerant to B-blockers
- pt has asthma

2. there is cocaine induced chest pain

3. there is coronary vasospam/prinzmetal angina
when is the pacemaker use in acute MI?

1. third degree av block

2. mobitz II, second degree av block

3. bifascicular block

4. new LBBB

5. symptomatic bradycardia

when do we use lidocaine or amiodarone in acute MI?

1. when there is v-tachycardia or v-fib

2. dont give anti-arrhythmic to prevent ventricular arrhythmias

what are the complication of MI?
1. hypotension

2. cardiogenic shock
a. dx: echo, swan ganz catheter
b. rx :ACEI, urgent revascularization

2.valve rupture
dx: echo
rx: acei, nitroprusside and urgent surgery

3. septal rupture
dx: echo, right heart catheter shows step in saturation from right atrium to right ventricle
Rx; ace, nitroprusside and urgent surgery

4. myocardial wall rupture
dx; echo
rx: pericardiocentesis, urgent cardiac repair

5. sinus bradycardia
dx: ekg
rx: atropine followed by pacemaker if there are still signs

6. third degree av block
dx: ekg-canon a waves
rx: atropine and pacemaker even if symptomes resolve

7. right venrticular infarction
dx; ekg
rx: fluid overload
how do we manage non-stemi?

1. no thrombolytics
2. heparin - lowers mortality
3. glycoprotein IIB/IIIA inhibitors lower mortality -especially in pts undergoing angioplasty

4. asa, oxygen, nitrates

when do we use glycoprotein IIA/IIIB inhibitors?
1. angioplasty and stents placements

2. nonsemi

3, stemi
what glycoprotein IIA/IIIB inhibitor has no benefit in STEMI?
abciximab
what is the treatment for stable angina?
1. asa and metoprolol - they lower mortality

2. nitrates - for pain, does not lower mortality
when do we use ACEI or ARBs?
1. used in stable angina and if pt has

a. congestive failure
b.systolic dysfunction
c. low ejection fraction
what are some side effects of ACEI or ARBs?
1. ACEI cause cough -so give ARBs

2. both cause hyperkalemia
what is the purpose of coronary angiography?
to see who needs bypass surgery not for diagnosis
what is the main difference b/w saphenous vein grafts and internal mammary atery grafts?
internal mammary artery grafts remain open for 10 years
what are the indications for CABG?
1. three coronary vessel disease with >70 % stenosis

2. left main coronary artery stensis >70%
what are the equivalents of coronary artery disease?
1. diabetes mellitus
2. peripheral aterial disease
3.aortic disease
4. carotid disease
what are the indications for statins?
1. acs and LDL > 100

2. the goal of LDL is <100

3. cad equivalent start when LDL>100
if pt has LDL and diabetes, when do we start therapy for LDL?
ldl goal <70
what are the risk factors in LIPID management?
1. tobacco use

2. high blood pressure ( >or = 140/90 or bp meds?

3. low HDL <40

4. family hx of early coronary ds

5. age ( males >45, female >55)
when is the goal of therapy an ldl <70?
coronary disease and diabetes
what are the adverse effects of statin therapy?
liver toxicity, so check ast and alt
what is the most common cause of erectile dysfunction after MI?
anxiety
what is the presentation of CHF?
1. sob on exertion
2. edema
3. rales on lung exam
4. ascites
5. JVD
6. orthopnea
7. PND
8. fatigue
what is the main treatment for acute pulmonary edema?
oxygen, furosemide, nitrates, and morphine
what tests need to ordered for a pt with chf?
cxr, ekg,oximeter, echo
what are the findings on cxr for a pt with CHF not controlled?
1. pulmonary vascular congestion
2. cephaliztion of flow
3. effusion
4. cardiomegaly
what are the findings on ekg for a pt with CHF not controlled?
1. sinus tachycardia
2. atrial and ventricular arrhythmias
what are the findings on oximeter for a pt with CHF not controlled?
1. hypoxia
2. respiratory alkalosis
why do we use echo in chf?
distinguishes systolic from diastolic dysfunction
pt with pulmonary edema from chf is given furosemide,oxygen, nitrates and morphine but pt continues to have symptoms, what is the next step ?
use positive inotropic agents in ICU
1. dobutamine ( DOC)
2. amrinone
2. milrinone
when do we use digoxin?
1. slow the rate of a-fib

2. not used for pulmonary edema
what is the treatment for v-tach, a-fib, a-flutter, svt caused by acute pulomary edema?
synchronized cardioversion
what is the treatment for sustained ventricular tachycardia that is hemodynamically stable?
lidocaine
amiodarone
procainamide
what are the right heart catheter findings of a pt with pulmonary edema?
1. dec cardiac output - due pump failur

2. increase wedge pressure - back of blood in left atrium

3. increase right atrial pressure - JVD

4. increase systemic vascular resistance
what are the right heart catheter findings of a pt with pulmonary htn?
1. dec co

2. inc sytemic vascular resistance

3. dec wedge pressure

4. inc right atrial pressure
what are the right heart catheter findings of a pt with septic shock?
1. inc co
2. decreased all other findings
what are the right heart catheter findings of a pt with hypovolemic shock?
1. systemic vascular resitance is increaesed

2. decreased all other findings
when pt has been stabilized after pulmonary edema from chf what is the next step?
1. do echo to differentiate b/w systolic or diastolic dysfunction
what are the management therapies for dilated cardiomyopathy or systolic dysfunction?
1. ACEI
2. BB ( carvedilol and metoprolol)
3. spironolactone
4. diuretics
5. digoxin
what are the management therapies for diastolic dysfunction chf?
1. BB
2. diurectics
what type of CHF has low ejection fraction?
systolic dysfunction
what are the indications for implantable cardiovert/defibrillators in chf?
used for dilated cardiomyopathy when ejection fraction is <35
what is the most common cause of death in CHF?
arrhythmia
when do we use biventricular pacemaker in chf?
severe chf and QRS duration 130 msec
what is the absolute contraindication for beta blockers?
1. symptomatic bradycardia
what is the clue to the diagnosis of mitral valve prolapse?
1. young female, general population

2. palpitations, atypical chest pain not with exertion
what is the clue to the diagnosis of mitral stenosis?
immigrants, pregnant
what is the clue to the diagnosis of bicuspid aortic valve?
1. tuners syndrome

2. coarctation of aorta
presentation of valvular heart diseases?
1. cause sob with exertion or exercise
what are the causes of systolic murmurs?
1. aortic stenosis

2. mitral regurgitation

3. mitral valve prolapse

4. hypertrophic obstructive cardiomyopathy (HOCM)
what are the causes of diastolic murmurs?
1. aortic regurgitation

2. mitral stenosis
all right sided murmurs increase with what?
insipiration

trucuspid stenosis
tricuspid regurgitation
pulmonic valves
all left sided murmurs increase with what?
expiration

mitral and aortic lesions
what maneuvers increase venous return?
squatting and leg raising
what maneuvers decrease venous return?
valsalva and standing up
what vavulvar heart diseases increase in intensity of murmur with squatting and leg raising ( venous return)?
1.aortic stenosis
2. aortic regurgitation
3. mitral regurgitation
4. mitral stensosis
5. all right sided lesions
what vavulvar heart diseases decrease in intensity of murmur with squatting and leg raising ( venous return)?
1. mvp
2. hocm
what are the effects of standing and valsalva on heart murmurs?
1. derease intensity of murmur excepts for MVP and HOCM which increase in intensity
what is the effect of handgrip?
increase afterload
what is the opposite of handgrip?
1.ace inhibitors - this decreases afterload

2. amyl-nitrate - vasodilator, it decreases afterload
what vulvular lesions are treated with ACEI?
AR and MR - improves murmurs

- so handgrip will worsen AR and MR murmurs by pushing blood back into the heart
what heart mumurs increase or get worsen with handgrip?
1. ar
2. mr
3. vsd
what murmurs improve or lessen with with handgrip?
1. mvp
2. hocm
what mumurs are increased or worsened by amyl-nitrate?
1. mvp
2. hocm
3. aortic stenosis
what is the effect of handgrip on aortic stenosis murmur?
decrease the murmur
cuz the gradient b/w aorta and LV is decreasing
what heart lesion has minimally effected by handdgrip or amynitrate?
mitral stenosis
where is aortic stenosis mumur best heard?
second right intercostal space and radiates to the carotid arteries
where is pulmonic valve mumurs best heard?
second left intercostal space
what murmurs are heard at lower left sternal borders?
1. aortic regurgitation murmur
2. tricuspid murmur
3. vsd murmurs
where is the murmur of mitral regurgitation best heard?
at the apex of the heart and radiates to the axilla
what is the best initial diagnostic test for valve lesions?
echocardiogram
what is the most accurate test for valve lesions?
left heart catheterization
what is the medical treatment for regurgitant valve lesions?
1. vasodilator therapy- acei, arbs, nifedipine
if regurgitant valve lesion are not getting better with medican managment, what is next?
surgical valve replacement
what is best treaments for stenotic valve lesions?
anatomic repair
what is best treatment for mitral stenosis?
balloon valvuloplasty, even if the pt is pregnant
what is best treatment for aortic stenosis?
surgical repair
if valsalva maneuvar improves murmur of valve lesion, what is the treatment for that lesions?
1. diuretics - (for as, ms, ar,mr, vsd)

2. not for mvp or hocm
if amynitrate improves murmur of valve lesion, what is the treatment for that lesions
1. acei- ( for AR, MR, VSD)

2. no for as, ms, mvp. hocm
what is presentation of aortic stenosis?
1. commonly present with chest pain, syncope and CHF are less common presentations

2. pt is older and has hx of htn, cad
what is the prognosis of aortic stenosis?
1. if coronary disease - 3-5 yrs

2. syncope - 2-3

3. CHF - 1.5-2
describe aortic stenosis murmurs?
1. crescendo - decrescendo systolic murmur

2. murmur increase in intensity with leg raising, squatting, amynitrate

2. murmur decreases in intensity with valsalva, standing, handgrip
what are the diagnostic testings for aortic stenosis?
1. TTE - initial test

2. TEE - accurate test

3. left heart catheterization- most accurate
a. shows gradient across the valve

4. ekg and cxr - show left ventricular hypertrophy
what is the treatment for aortic stenosis?
1. diuretic-initial

2.be careful with over diuresing

3. tx of choice is valve replacement
what is the presentation of aortic regurgitation?
1. pts usually have hx of
2. htn
3. rheumatic heart dz
4. endocarditis
5. cystic medical necrosis
6. marfan
7. ankylosing spondylitis
8. syphilis
9. reactive arthritis
10. pts presents with sob and fatigue
what is reactive arthritis?
1. inflammatory arthritis of large joints
2. inflammation of eye ( conjunctivitis and uveities
3. urethritis
4. also reiters syndrome
what are the physical findings of AR?
1. diastolic decrescendo mumur at left sternal border
2. murmurs increases with leg raising, squatting and handgrip
3. quinke pulse - arterial or capillary pulsations in fingernails
4. corrigans pulse - high bounding pulses
5. musset sign - head bobbing
6. duroziez sign - murmur over femoral arter
7. hill sign- blood pressure gradient higher in lower extermity
what are the diagnostic testing for AR?
1. TTE - initial tes

2. TEE-more accurate

3. left hear catheterization - most accurate
what is the treatment for AR?
1. acei, arbs and nifedipine - initial

2. loop diuretics also

3. surgery - if EF <55 or LVES diameter >55mm, even if asymptomatic

4.
what is the presentation of mitral stenosis?
1. rheumatic fever is the mcc
2. look for immigrant pts
3. look for pregnant pts
4. dysphagia - big atria pressing on esophagus
5. hoarseness - pressure on recuurent laryngeal nerve
6. a-fib - lead to stroke
what are the physical exam findings of ms?
1. diastolic rumble after opening snap
2. loud s1
3. ms worsens opening snap moves close to s2
4.murmur increase with leg raising, squatting, expiration
what are the diagnostic test for ms?
1. TTE - initial
2. TEE - more accurate
3. left heart cath - most accurate
4. ekg and cxr - show left atrial hypertrophy
what is the treatment for ms?
1. diuretics -initia
2. balloon valvuloplasty-most effective
3. pregnant pts-balloon
what is presentation of MR?
1. MR is caused by htn, ischemic heart disease and any other heart condition that leads to dilation of heart
3. dyspnea on exertion is the most common presentation
what are the physical exam findings of MR?
1. holosystolic murmur that obscures both s1 and s2
2. heard best at apex and radiates to axilla
3. mumur increase with leg raise, squatting, and handgrip
4. standing, valsalva and amyl nitrate - dec in intensity
3. s3 gallop heard
what is the diagnostic test for MR?
1. TTE - initial
2. TEE - accurate
what is the treatment for MR?
1. acei, arbs, nifedipine - initial
2. loop diuretics
3. surgery when EF <60% or LVES diameter >45mm even if pts asymptomatic
what is the criteria for surgery in AR?
1. EF <55

2. LVES diameter >55mm
what is the criteria for surgery in MR?
1. EF <60

2. LVES diameter >45mm
what is the presentation of ventricular septal defect?
1. asymptomatic pts may present with holosystolic mumur at the lower left sternal border

2. large defects lead to sob

3. murmurs worsens with exhalation, squatting, and leg raise
what is the diagnostic test for VSD?
1. echo - first

2. catheterization - shows the degree of shunting
what is the treatment for VSD?
mild defects can left with out closure
what is the presentation of ASD?
1. small asd are symptomatic
2.large defect may lead to sob or signs of right ventricular failure like
3. sob and parasternal heave
4. asd is associated with fixed splitting of s2
what is the treament of asd?
1. percutaneous or catheter devices are common

2.repair when shunt ratio ?1.5 to 1
what is s3 associated with??
1. fluid overload states
in chf or mr

3. normal before 30yrs of age
what causes wide s2 heart sound where p2 is delayed?
1. rbbb
2. pulmonic stenosis
3. RVH
4. pulmonary htn
what causes paradoxical splitting of S2 heart sound where a2 is delayed?
1. LBBBB
2. aortic stenosis
3. LVH
4. htn
what causes fixed splitting of s2?
asd
what is the presentation, testing for dilated cardiomyopathy?
1. presents same as chf

2. dx:
a . echo -initial
b. MUGA scan - most accurate

3.
what are the causes of dilated cardiomyopathy?
1. ischemia
2. etoh
3. adriamycin
4. radiation
5. chagas disease
what is the treatment for dilated cardiomyopathy?
1. acei
2. arbs
3. bb
4. spironolactone
5. digoxin
what is the presentation, testing , treatment for cardiomyopathy?
1. presents with sob on exertion and s4 gallop

2. dx: echo

3. tx: BB and diuretics, no digoxin and spironolactone
what are the causes of s4 heart sound?
1. it means LVH and decreased compliance or stiffness of the ventricle

2. no additional therapy needed
what is the presentation of restrictive cardiomyopathy?
pt have hx of
1. sarcoidosis
2. amyloidosis
3. hemochromatosis
4. cancer
5. myocardial fibrosis
6. glycogen storage disease
7. sob more common
8. kussmauls sign: inc in jvd on inhalation
what is the tx for restrictive cardiomyopathy?
diuretics and correct underlying cause
what are the diagnostic testings in restrictive cardiomyopathy?
1. cardiac cath shows rapid x and y descent
2. ekg - low voltage

3. endomyocardial bx- most accurate

4
what is the presentation of pericarditis?
1. chest pain is pleuritic -changes with respiration
2. positional - relieved by sitting up and leaning forward
3. sharp and brief pain
4. majority due to virus
what is the physical exam findings in pericarditis?
1. friction rub
what is the treatment for pericarditis?
1. NSAIDS - like indomethacine, naprosyn, asa, Ibuprofen

2. if pain persist - give prednisone orally
what is the presentation of pericardial tamponade?
1. presents with sob, hypotension, and JVD

2. pulsus paraodxus - dec in bp>10 on inhalation

3. electrical alternans: alteration of qrs complex on ekg
what are the dignostic testing for pericardial tamponade?
1. echo - accurate

2. shows diastolic collapse of the right atrium and right ventricle

3. ekg - low voltage and electrical alternans; variations of height of qrs complex from heart moving backward and forwards

4. right heart cath - equalization of all the pressures in heart during diastole

5. wedge pressure will be same as right atrial and pulomanry artery diastolic pressures
what is the treatement for pericardial tampondae?
1. pericardioentesis - initial

2. pericardial window placement - most effective long term

3. diuretics - most dangerous therapy
what is the presentation of constrictive pericarditis?
1. presents with sob and signs of chronic right heart failure

2. edema
3. jvd
4. hepatosplenomegaly
5. ascites
what are the unique features of constrictive pericarditits?
1. kussmauls sign: inc in jvd on inhalation]

2. pericardial knock; extra diastolic sound from the heart hitting a calcified thickedened pericardium
what are the diagnostic testing in constrictive pericarditis?
1. cxr - showing calcification

2. ekg - low voltage

3. ct and mri - showing thickening of the pericardium
what is the treatment for constrictive pericarditis?
1. diuretics - initial

2.surgical removal of the pericadium - most effective
what is the presentation of the dissection of thoracic aorta?
1. chest pain radiating to the back b/w scapula

2. pain that is severe and ripping

3. difference in blood pressure b/w right and left arms

4. hx of htn
what are the diagnostic testing for the dissection of the aorta?
1. cxr - shows wide mediastinum

2. ct angio - most accurate
what is the treatment for dissection of the aorta?
1. beta blockers - lower bp

2. labetalol
when do we so screening for AAA?
1.screen with u/s should be ordered in >65 in pts who are smoker or were smokers

2. if >5cm - surgical repair

3. stop smoking to step the progression
what is the presentation of peripheral arterial disease?
1. PAD presents with claudication- pain on calves on exertion

2. smooth , shiny skin with loss of hair and sweat glands

3. loss of pulse in the feet
what are the diagnostic testing for PAD?
1. ABI - initial test
-normally pressure is greater in legs

2. most accurate test: angiography
what is the treatment for PAD?
1. asa
2. blood pressure control with ACEI
3. exercise as tolerated
4. cilostazol
5. lipid control with statins for target LDL <100
6. marginally effective - pentoxyfilene
7. CCB - not effective
if pt has pain + pallor + pulseless?
arterial disease
describe the pain of spinal stenosis?
1.pain that in worse when going downhill and less with walking uphill or while cycling or sitting

2. normal skin and pulses
describe acute arterial embouls?
1. will be very sudden in onset with loss of pulse and cold extremity

2. painful

3. as and a-fib are often in the history
what is the presentation of a-fib?
1. presents with palpitations and an irregular pulse in a person with hx of htn, ischemia, or cardiomyopathy
what are the diagnostic testing for a-fib?
1. ekg

2. if ekg shows no answer place them on telemetry monitoring

3.holter monitoring - for oupts who are hemdynamically stable

4. echo
5. thyroid test
6. troponin and ck-mb levels
7. electrolytes
what is the treatment for a-fib?
1. unstable pts should undergo synchronized electrical cardioversion

2. instability: systolic pressure < 90, chf, confusion, chest pain

3. in stable pts ventricular rate control if >100

4.use bb, ccb, digoxin

5. if rate controlled- anticoagulate with warfarin if greater >2days with INR 2-3
what is the presentation of atrial flutter?
1. managed same way as a-fib

2. onyly difference in rhythm is regular
what is the advantage of using BBs ( metoprolol, esmolol) for a-fib or a-flutter?
better if pts have
1. ischemic heart dz
2. migraines
3. graves
3. pheochromocytoma
what is the advantage of using CCBs ( diltiaazem) for a-fib or a-flutter?
1. asthma
2. migrraine
what is the advantage of using digoxin for a-fib or a-flutter?
borderline hypotension
what is the presentation of multifocal atrial tachycardia ( MAT?
1. presents like atrial arrhythmia in association with copd/emhysema

2. ekg- polymorphic p waves

3. pts ahve tachycardia >100

4. MAT manifests as irrgular choatic rhythm on ekg

5. do not use BB or digoxin
what is the presentation of supraventricular tachycardia?
1. presents with palpitations and tachycardia
2. syncope
3. not associated with ischemic heart dz
4. svt has regular rhythm with ventricular rate of 160-180
what is the diagnostic testing of supraventricular tachycardia?
1. ekg

2. order holter monitorin or telemetry in sensitivity
what is treatment for svt?
1. for unstable pts: synchronized cardioversion
2. stable pts: vagal maneuvers ( carotid sinus massage, ice immersion of face, valsalva)
3. if vagal maneuvers dont work - give Iv adenosine
what is the long term managment for svt?
radiofrequency catheter ablation
what is the presentation of wolff-parkinson-white syndrome ( wpw)?
1. wpw presents as svt that can alternate with v-tach

2. other clue is worsening of svt after the use of CCB or digoxin
what are the diagnostic testing for wpw?
1. delta wave on ekg

2. most accurate test : electophysiologic studies
what is the treatment for wpw?
1. procainamide

2. long term therapy: radiofrquency catheter ablation
what is the presentation of v-tach?
1. present as palpitations,syncope, chest pain, or sudden death

2.
what are the diagnostic testings for v-tach?
1. ekg
2. telemetry monitoing
3.most accurate- electrophysiologioc studies
what is the tx for persistent v-tach in hemodynamically stable pts?
1. amiodarone
2. lidocaine
3. procainamide
4. mg
what is the tx for persistent v-tach in hemodynamically unstable pts?
synchronized cardioversion
what is the presentation of v-fib?
presents with sudden death
what is the testing of v-fib?
ekg
what is the tx for v-fib?
1. unsynchronized cardioversion

2.
describe torsade de pointe?
this is v-tach with undulating amplitude

give mg addition of medical or electrical therapy
what are the step for unsynchronized cardioversion>
1. cpr
2. reattempt defib
3. give IV epi or vasopressin
4. reattempt defib
5. give iv amiodarone or lidocaine
6. give defib
7. repeat cyleces
what are the causes of sudden syncope or LOC?
1. cardiac causes
2. neurologic (seizures)
what are causes of gradual loss of consciouness?
1. toxic metabolic problems
2. hypoglycemia
3. drug toxicity/intoxication
4. anemia
5. hypoxia
in eval of syncope.
ask was the regaining of consciouness sudden or gradual?
1. sudden regaiining
a. cardaic
b. rhythm disorders
c. structural dz

2.gradual
a. neuro ( seizures)
IN EVAL of syncope
what is cardaic exam?
normal exam
1. v-arrhythmia

cardiac exam abnormal
1. as
2. hocm
3. ms
4. mvp
what are the diagnostic testings in syncoope?
1. cardio and neuro exam
2. ekg
3. chemistries
4. oximeter
5 cbc
6. cardiac enzymes
what is tx for syncopre?
1. tx for specific cause

2. important thing is to exclude cardiac cause

3. if v-arrhthima - defibrillator